Common use of MEDICARE ASSIGNMENT Clause in Contracts

MEDICARE ASSIGNMENT. I certify that the information given by me in applying for payment from any third party payor, including payment under Title XVIII of the Social Security Act, is correct. I request that paymentof authorized benefits be made in my (or the patient’s) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B, including but not limited to the effective date of such coverage. I also authorize Mercy to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

MEDICARE ASSIGNMENT. I certify that the information given by me in applying for payment from any third party payor, including payment under Title XVIII of the Social Security Act, is correct. I request that paymentof payment of authorized benefits be made in my (or the patient’s) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B, including but not limited to the effective date of such coverage. I also authorize Mercy to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

MEDICARE ASSIGNMENT. I certify that the information given by me in applying for payment from any third party payor, including payment under Title XVIII of the Social Security Act, is correct. I request that paymentof payment of authorized benefits be made in my (or the patient’s) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B, including but not limited to the effective etfective date of such coverage. I also authorize Mercy to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

MEDICARE ASSIGNMENT. I certify that the information given by me in applying for payment from any third party payor, including payment under Title XVIII of the Social Security Act, is correct. I request that paymentof payment of authorized benefits be made in my (or the patient’s) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B8, including but not limited to the effective date of such coverage. I also authorize Mercy to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

MEDICARE ASSIGNMENT. I certify that the information given by me in applying for payment from any third party payorpayer, including payment under Title XVIII of the Social Security Act, is correct. I request that paymentof payment of authorized benefits be made in on my (or the patient’s) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B, including but not limited to the effective date of such coverage. I also authorize Mercy the hospital and my physician(s) to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claimclaim(s).